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DESCRIPTIONActive specific immunotherapy with therapeutic melanoma vaccines is proposed for selected categories of patients with malignant melanoma. The goals of treatment with melanoma vaccines include tumor regression, prolongation of disease-free and overall survival, and improved quality of life. Active specific immunotherapy is designed to elicit an immune response by recruiting specific effector cells to produce antibodies or a T-cell response directed against one or more specific tumor antigens. This is in contrast to active immunotherapy using nonspecific agents, such as cytokines, that stimulate the immune system globally; and passive immunotherapy with agents, such as monoclonal antibodies, that directly or indirectly mediate tumor killing.
At the present time, no melanoma vaccine has received approval from the FDA.
POLICYMelanoma vaccines are considered investigational.
Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
POLICY HISTORY2/2001: Approved by Medical Policy Advisory Committee (MPAC), ICD-9 diagnosis code 154.2-154.3, 172.0-172.9, 184.0-184.2, 184.4, 187.1, 187.4, 187.7, 187.9, 190.0-190.3, 190.5-190.6, 190.9 added
7/5/2001: Code Reference section updated, ICD-9 diagnosis code 197.5, 198.2, 198.4, 198.82, 230.5-230.6, 232.0-232.9, 233.3, 233.5-233.6, 234.0 added
7/12/2001: Hyperlinks added
2/14/2002: Investigational definition added
4/18/2002: Type of Service and Place of Service deleted
10/20/2004: Code Reference section updated, non-covered ICD-9 diagnosis code 154.2-154.3, 172.0-172.9, 184.0-184.2, 184.4, 187.1, 187.4, 187.7, 187.9, 190.0-190.3, 190.5-190.6, 190.9, 197.5, 198.2, 198.4, 198.82, 230.5-230.6, 232.0-232.9, 233.3, 233.5-233.6, 234.0 deleted
11/7/2005: Code Reference section updated; ICD-9 diagnosis code V58.12 added
7/10/2009: Policy reviewed, no changes
08/02/2011: Removed "Active Specific Immunotherapy with Therapeutic" from the policy title and statement.
SOURCE(S)Blue Cross Blue Shield Association policy # 2.03.04 and # 8.01.01
Hayes Medical Technology Directory
CODE REFERENCEAll codes are considered investigational and not eligible for coverage.